Improved Monitoring of Entitlements to pharmaceutical benefits

Background

The IME is supported by the National Health Amendment (Improved Monitoring of Entitlement of Pharmaceutical Benefits) Act 2000.

Before we reimburse you for dispensing prescriptions we identify the patient and check they’re eligible.

We use:

• the patient’s Medicare card number or Veterans’ Affairs file number you provide in your claim
• the patient’s concession card number if provided in your claim.

This is how we identify the patient and check their eligibility.

Pharmacy and public hospital admissions or emergency staff can call the IME enquiry line to get details for patients who need subsidised PBS medicines. This includes all of the following:

• Medicare card details
• concessional entitlement card details
• a DVA file number for a patient who requires medicine subsidised by the PBS.

Remember to get the patient’s consent to access this information.

You can contact the IME enquiry line by calling us on the PBS general enquiries line and selecting option 1.

We can only release the information for a maximum of 2 patients per call.

There will be exceptions to this rule. For example, if your pharmacy services a nursing home and you need a bulk number of patient detail requests.

Benefits

This measure helps ensure taxpayers’ dollars go to those who are entitled to them. The IME checks the patient’s entitlement arrangements. This reduces the number of subsidies paid to ineligible people.

The IME doesn’t change patient entitlements for medications listed on the PBS.

Proof of eligibility

Most patients only need to provide their Medicare card number when they get prescriptions filled for Pharmaceutical Benefits Scheme (PBS) subsidised medicines.

To receive an additional subsidy, concession card holders also have to provide their concession card number.

Veterans covered by the Repatriation Pharmaceutical Benefits Scheme (RPBS) need to provide their Veterans’ Affairs file number. This is on their Gold, White or Orange card.

White card holders have to provide their Medicare card number for prescriptions not covered under the RPBS.

People collecting prescribed medicines for someone else must provide proof of that person’s eligibility to receive PBS-subsidised medicines.

Visitors to Australia

People visiting from countries with a Reciprocal Health Care Agreement who haven’t been issued with a Medicare card, should show their passport to the pharmacist when having prescriptions filled.

Patients without a Medicare card number

Sometimes patients who are entitled to receive pharmaceutical benefits can’t provide a Medicare card number. Patients who don’t know their Medicare number can either:

• call and ask the person who holds their card for the number
• contact Medicare general enquiries.

If an eligible patient doesn’t know their number, they can pay the full price for the medication and get a refund later. They can get a refund from a Medicare office or DVA state office. They’ll need a PBS patient refund receipt from you.

Medicare special numbers

There’s some situations where you can use a Medicare special number for an eligible patient who can’t provide one. For example in an emergency or if the patient is an eligible overseas visitor.

National Health (Entitlement to Pharmaceutical Benefits - Special Evidentiary Categories) Determination 2017 supports the use of Medicare special numbers.

Only use a Medicare special numbers if the circumstances fit. You can’t use Medicare special numbers when you record vaccines on the Australian Immunisation Register (AIR).

There are 6 Medicare special numbers available:

Compliance

We encourage people to comply with the programs we administer.

We monitor how you use Medicare special numbers and conduct audits to check pharmacists and doctors are using them appropriately. It’s the pharmacist and doctor’s responsibility to make sure they use Medicare special numbers appropriately.